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Wellcare Simple (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in FL. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Wellcare Simple (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Wellcare Simple (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Wellcare Simple (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $420.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Wellcare Simple (HMO) plan has a $420 deductible for prescription drugs. In the initial coverage phase, after the deductible is met, you'll pay varying costs depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred and mail order pharmacies, while standard generic drugs have 25% coinsurance. Specialty tier drugs have no copay, and once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy (LIS), you may have reduced premiums and no cost-sharing.
Additional Benefits
The Wellcare Simple (HMO) plan offers comprehensive coverage, including inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services with a $140 copay. It also provides coverage for primary care with no copay, preventive services with no copay for several services, and vision and dental services with no copays for routine exams and eyewear, and a $25 copay for other dental services. This plan includes additional benefits such as hearing services with a copay, home health services with no copay, and medical equipment with coinsurance. Additionally, it covers ambulance services, and home infusion and dialysis services with copays or coinsurance. This plan also offers an OTC benefit with no copay, and meal benefits with no copay.
Inpatient Hospital See details
Inpatient Hospital services are covered by the Wellcare Simple (HMO) plan, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $250 copay for days 1-6, and no copay for days 7-90, with 10 additional days covered with no copay. For Inpatient Hospital Psychiatric, you will pay a $400 copay for days 1-5, and no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $450, observation services with a copay between $140 and $450, and ambulatory surgical center (ASC) services with a $125 copay. Outpatient substance abuse services have a copay of $40 per session for both individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Wellcare Simple (HMO) covers partial hospitalization with a $130 copay, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance services are covered by Wellcare Simple (HMO), with a $235 copay for both ground and air ambulance services, and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Wellcare Simple (HMO) plan, with a $140 copay and no coinsurance. Urgently Needed Services have a $25 copay and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $140 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) covers primary care physician services with no copay. Chiropractic services have a $20 copay, and routine chiropractic care has a $20 copay for up to 12 visits per year. Occupational therapy services, physician specialist services, and physical/speech therapy have a $25 copay. Individual and group mental health and psychiatric sessions have a $40 copay. Other health care professionals have a copay between $0 and $25. Additional telehealth benefits have a copay between $0 and $40. Opioid treatment program services have a $25 copay.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services with no copay for an annual physical exam and no copay for several other preventive services, including glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit. Additional preventive services have a copay; however, Health education, In-home safety assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Kidney Disease Education Services are covered with 20% coinsurance.
Hearing Services See details
The Wellcare Simple (HMO) plan covers hearing exams with a $25 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with no copay, but inner ear, outer ear, and over the ear prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $25, and eyewear with no copay, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered with no copay, once per year. Eyewear has a combined maximum benefit of $200 per year.
Dental Services See details
Dental Services include coverage for Medicare dental services with a $25 copay, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with no copay, while maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellcare Simple (HMO) plan, but require a doctor's referral. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance, and Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay between $0 and $40, Lab Services with no copay, Diagnostic Radiological Services with a copay of up to $250, Therapeutic Radiological Services with 20% coinsurance, and Outpatient X-Ray Services with a $75 copay. All services require prior authorization and a doctor referral.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with a doctor referral. However, none of the listed sub-services are covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor's referral. For days 1-20 and 51-100, there is no copay, while days 21-50 have a $214 copay. Additional days beyond Medicare-covered for SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Wellcare Simple (HMO) plan covers Over-the-Counter (OTC) items with no copay and a maximum benefit of $145 every three months. The plan also covers meal benefits with no copay, but a doctor's referral is required. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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